Provider Demographics
NPI:1942069141
Name:GLASS, TIMOTHY WALKER
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:WALKER
Last Name:GLASS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9438 W SELLS DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-0845
Mailing Address - Country:US
Mailing Address - Phone:928-279-6768
Mailing Address - Fax:
Practice Address - Street 1:19555 N 59TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6813
Practice Address - Country:US
Practice Address - Phone:928-279-6768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program